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Swallowing difficulties (dysphagia)

If our swallow works well, food, drink and our own fluids such as saliva, go safely to the stomach. If a person’s swallow does not work properly, food, drink or other fluids could go down “the wrong way” to the lungs instead of stomach. Being dependent on others for eating and drinking (needing a carer to raise food/drink to lips) is one of the biggest risk factors that can lead to aspiration pneumonia.

A speech and language therapist (SLT) can help you manage dysphagia by advising on safe textures of food, thickness of drinks, positioning at meal times, physical support, prompting, communication and environment at meal times.

General strategies for safe eating and drinking at meal times if you are supporting a person to eat/drink:

Do's	Don'ts
Always follow SLT guidelines!  Slow pace of eating and drinking – lots of time needed to swallow and then breathe afterwards Give spoonfuls at the level of the person’s mouth – not leaning over from above Sit down when fully supporting the person Person should be positioned as upright as possible with feet supported	Don’t give food if the person is too drowsy If the person coughs, do not “wash food down” with a drink Avoid too much talking/laughter and jokes whilst eating/drinking

 

It is vital to know and recognise signs the common signs of aspiration at meal and drink times

• Coughing during or just after meals/drinks
•  Difficulty breathing: the person may breathe rapidly, gasp or wheeze (look at movement of chest)
• A wet or gurgly voice around mealtimes
•  Eyes watering at mealtimes
•  Raised temperature
•  Change in skin colour
•  Any signs of pain/discomfort when eating/drinking

 

Poor oral hygiene

There is a strong relationship between poor oral health and developing pneumonia, which can easily be prevented with effective daily oral care and frequent dental check ups.

Regular cleaning and toothbrushing is proven to reduce the risk of aspiration pneumonia as part of an effective oral hygiene routine:

1. Inspect the mouth
2. Remove food debris daily with gauze or cotton wool
3. Tooth-brushing twice a day at a minimum and after food if possible
4. Denture cleaning - a) Daily cleaning with a toothbrush and soap,  b) Removal of food debris stuck to the denture,  c) Leave dentures soaking in water overnight
5. Apply or use a mouth and lip moisturiser

If a person has an unsafe swallow consider the use of a non foaming toothpaste, brush their teeth without wetting the toothbrush and sit them as upright and forward as is practical and comfortable when doing toothbrushing. 

Reflux

Stomach acid/contents can come back up into the back of your mouth, this can be due to positioning/posture, weak muscles (incl. PEG tube feed)

If stomach contents are inhaled into the lungs instead of swallowed back into stomach, this can increase the risk of getting aspiration pneumonia. Signs that this is happening can be:

• pain/rubbing chest during/straight after meals
• vomiting after meals
• coughing outside meals, especially in the mornings.

To manage this avoid:

• very acidic foods
• high fat foods
• spicy foods
• fizzy drinks
• large heavy meals or seek advice from a GP for medication/further investigation.

Excess saliva

Swallowing problems can also make it difficult to swallow saliva, and you  may see saliva loss from lips

Some medications can increase saliva production, making it harder to swallow

Reflux may increase production of saliva.

Dry mouth

Can be caused by medication, dehydration, mouth breathing at night causing saliva can become thick and sticky making it difficult to swallow. This in turn creates a higher risk of aspiration

Give oral care to clear thick saliva – use toothbrush (avoid pink swabs – choking risk)

Then offer drinks for hydration

If you notice any changes in saliva appearance or management e.g. increased coughing on saliva or loss from lips – it is important to discuss with your GP in case of a treatable infection/condition.

Low weight

Low weight/unplanned weight loss can be a long term symptom of aspiration as a person may be having many chest infections subsequently eating less, and losing more weight. They may be reluctant to eat due to aspiration

Low weight can lead to:

• malnutrition
• dehydration
• reduced ability to fight off infections – including chest infection, UTIs, and, skin breakdown.

It is important to liaise with your GP for any further investigations into underlying causes, this might lead to a referral to a dietitian who can help with increasing calorie content of foods/drinks, supplements.

Weak cough

A strong, effective cough is important for maintaining a clear airway and respiratory health.

A weak cough leads to a cycle of retention of secretions, which leads to activation of inflammation, which leads to excessive and thick secretions which are difficult to clear with a weak cough.

This can be helped by:

• vocalising
• shouting
• laughing
• movement and activity, and with the support of a physiotherapist.

Chest wall deformity

Chest wall deformity which results from changes to the shape of the spine can:

• alter shape and function of the lungs and internal organs
• reduce chest wall compliance/flexibility
• lead to weak respiratory muscles
• weaken the person’s cough.

Support with management of this will come from a physiotherapist.

Immobility

Physical exercise is an important part of keeping healthy and for normal airway clearance.

It can be difficult to think of ways to engage people with a learning disability in activity and movement especially when the person’s mobility is limited, be creative and move!

• Change position regularly
• Avoid spending long periods of time in one position
• Therapeutic activities such as rebound therapy and hydrotherapy.

Constipation

Constipation can impact respiratory health because of bloating which leads to:

• reduced lung expansion
• excessive saliva
• increased seizure activity
• loss of appetite
• reflux

 Up to half of all people with a learning disability have constipation and unrecognised, untreated constipation has been known to cause death.

Epilepsy

Epilepsy impacts on respiratory function because of fluctuating levels of arousal associated with seizures can impact on:

• dysphagia
• posture and movement
• saliva control.